Monday, January 28, 2008

How Insurers Fail to Serve Their Customers

In 2001, a patient at age 22 crashes their car and is found to be in ventricular fibrillation by police who arrive on the scene. Amazingly, patient is successfully defibrillated before being removed from the car. This patient was later found to have Long QT syndrome. A single ICD was placed. The patient did well, but later had recalled ICD battery in 2005, which was also replaced. No problems since.

This patient has been carefully followed every three months in our clinic since. Seen once in 2006 for another appropriate ICD shock.

Lots of visits. Lots of records taken - all recorded on an electronic medical record. Patient is covered by insurance.

Today, a letter arrives from this patient's insurance company:

"Dear Doctor or Provider:

Thank you for your recent claim. We appreciate the opporunity to be of service to you.

Unfortunately, we are unable to process the claim due to the reason(s) listed below:

Date of placement for defibrillator, the MD evaluation of patients cardiac status prior to the date and medical necessity for the device.

Please submit the information requested above. Once we receive the requested information, we will be happy to complete our review.

You call yourself a "Customer Advocate?" How, exactly, does this advocate for your customer? It seems to me that this is another effort to ration care and deny your "customer," my patient, from payment as you promised this individual. Please shove your little computer-generated form letter up where the sun never shines.

You have access to the electronic medical record, as you know, as the patient has granted you access to their record for reimbursement purposes. Please take a few minutes of your precious time to review the record and all of the previous reimbursements you have paid for the indication for this individual's device. The patient's past medical events are clearly documented, as we are required to do each time we see the patient so we can get paid. Further, your attempts to ration care like this and delay reimbursement have resulted in significant legal actions against insurers in other states who have generated similar delays to physician payment.

Sorry I had to notify the world about your lack of "customer service" to my patient.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.